Surrey's area coroner has demanded a review of mental health procedures after a woman jumped under a train two days after being released by psychiatrists following a previous suicide attempt.

Simon Wickens will write to the Secretary of State for Health after finding "concerns" in the way Woking resident Julia Hayward was discharged before her death last year.

The 55-year-old, who suffered from depression, was detained under the Mental Health Act after running out in front of a lorry on May 21 last year, but released later that day.

The inquest heard there had been confusion between the deceased’s doctor and family as to how closely she needed to be monitored at home after he decided not to detain her in a secure psychiatric unit.

In the weeks before her death the mother of one, who had battled depression since she was 18, had become "increasingly anxious" over whether to change jobs.

Announcing his findings following the two-day inquest on Tuesday (August 11), Mr Wickens said: “What has concerned me is the issue about the care plan when a patient is released into the community.

“Consideration is to be given as to when someone is discharged to a loved-one how that should be recorded and the information passed on, whether that should be in documentary form so that loved ones are aware of what is involved.”

The coroner will send a 'Prevention of Future Deaths' Report to relevant authorities.

Earlier in the day the coroner heard that Mrs Hayward had been assessed for more than an hour and a half by Dr Dilraj Singh following her initial suicide attempt.

He told the inquest she had expressed regrets for her actions and shown insight into her condition.

This had tipped the balance in favour of allowing Mrs Hayward home, said Dr Singh, despite worries that she might have further impulsive suicidal thoughts and that she had admitted to previously looking up train timetables with a view to ending her life.

While Dr Singh told the inquest he had released Mrs Hayward on the understanding she would be "kept under a watchful eye" 24-hours a day, under questioning from the coroner he conceded that it was possible he had not made this clear.

Giving evidence for the second time during the inquest, Mr Melvin said: “It was not my understanding that I needed to watch over Julia 24/7 and not let her out of my sight.

Dr Singh said he had concluded on May 21 2014 that Mrs Hayward presented a "medium risk" and that he had offered her voluntary committal to the secure mental health unit, but that she had refused.

The coroner told the psychiatrist he found the issue of communication with the deceased’s family "troubling".

“Somebody may be able to provide 24-hour support,” he said.

“As to whether they have actually agreed to do so is a different matter.

“You say there is a possibility that it was not made plain.”

Delivering a narrative verdict, Mr Wickens said he was sure Mrs Hayward had jumped under the train as a "deliberate act", but that he could not give a formal verdict of suicide because the absence of conclusive toxicology and blood-alcohol data meant he could not be sure of her intentions.

“She was clearly very loved and supported,” said the cornoner.

“Julia did find enjoyment in life.

“I have found evidence of a loving wife and loving mother.

“She was an outgoing and sociable person."

Mr Wickens added: “But Julia always battled.

“Her battle with depression was a long one and, despite help, one she was not necessarily winning.”

Mr Wickens said suggestions raised by family members that a change in Mrs Hayward's menopause treatment a few months before she died had materially exacerbated her mental state were "speculative".

He praised Mr Melvin and Andrew Hayward, the deceased’s son, for the dignity they had shown throughout proceedings.